Application Forms
We have prepared various application forms in Excel format (some formats are in Word format) and fill out examples in PDF format.
If you want to input directly on various application forms, please download it to your PC before use.
If you want to input directly on various application forms, please download it to your PC before use.
* Excel can be opened in ods format, but please save in Excel format.
Document submission destination
|
Works Applications Works Applications・Systems Works Applications・Enterprise Works Applications・Furontia |
Works Applications Human Resources Service Center |
|---|
* Please send documents such as post-retirement, traffic accidents, medical expenses and treatment procedures directly to Health Insurance Society.
Procedures for increasing / decreasing family members and losing insurance cards
The number of dependents increases
* Please see here for necessary attachments.
| Health Insurance Dependent Notice(Change) | EXCEL |
|---|---|
| National Pension No. 3 Insured Notification * Not required when applying for a spouse under the age of 20 or over 60 as a dependent |
EXCEL |
| Current Circumstances of Dependent to Be Covered | EXCEL |
| Certificate of Conditions of Employment | EXCEL |
| Certificate of Retirement or De-registration as a Temporary Worker | EXCEL |
When a child is born
| Health Insurance Insured person Family Claim for Childbirth and Childcare Lump-sum Allowance and Additional Allowance (When not using the system of direct payment to medical institutions/yhe system of receipt directly by a medical institution on your behalf, OR if childbirth took place outside of Japan) |
EXCEL |
|---|---|
| Health Insurance Insured person Family Claim for Payment of Childbirth and Cjildcare Lump-sum Allowance and Additional Allowance (To apply for receipt directly by a medical institution on your behalf) |
EXCEL |
The number of dependents decreases
| Health Insurance Dependent Notice(Change) | EXCEL |
|---|
The person or family member has died
| Health Insurance Insured Person Family Claim for Payment of Funeral Fees | EXCEL |
|---|
You lose your health insurance card, elderly beneficiary card, or certificate of limit application
| Insurance Card/Elderly Recipient/ Certificate Reissue due to Loss or Damage Application Form |
EXCEL |
|---|
Acquisition / loss certificate is required
| Health Insurance Date of Acquisition /Loss of Qualification as an Insured Person Date of Dependent Status Certification/Deletion Certification Request Application | EXCEL |
|---|
Replacement payment procedure
Paying in advance
| Health Insurance Insured Person Claim for Payment of Medical Care Costs Family Member | EXCEL |
|---|---|
| Itemized(Medical Treatment)Receipt | EXCEL |
| Health Insurance Insured Person Claim for Payment of Medical Care Costs Family Member (acupuncture) |
EXCEL |
| Health Insurance Insured Person Claim for Payment of Medical Care Costs Family Member (massage) |
EXCEL |
Receiving treatment overseas
| Health Insurance Insured Person Family Claim for Payment of Medical Care Costs | EXCEL |
|---|---|
| Agreement of Authorization | WORD |
| Attending Medical fee Statement | EXCEL |
| Attending Physician's Statement | EXCEL |
| Table of International Classification of Diseases for the use of Social Insurance | EXCEL |
| Itemized Receipt (Internal medicine ophthalmology) |
EXCEL |
| Itemized Receipt | EXCEL |
| Attending Dentist's Statement | EXCEL |
| Attending Dentist's Statement (Japanese translation) |
EXCEL |
Procedures related to medical expenses and treatment (Certificate of application of limit amount / Certificate of specific disease patient)
Medical expenses are likely to be high
| Request for Issue of Health Insurance Eligibility Certificate for Ceiling-Amount Application Form | EXCEL |
|---|
When it corresponds to a specific disease
| Health Insurance Request for Issuance of Certificate Issued for Specific Disease Treatment Application | EXCEL |
|---|
Procedures when you cannot work
Maternity leave
| Health Insurance Claim for Payment of Maternity Allowance * Please print in A3 size |
EXCEL |
|---|
Sick leave
| Health Insurance Claim for Injury and Illness Allowance * Please print in A3 size |
EXCEL |
|---|---|
| Certificate of Consent * Only for initial application |
WORD |
| Attachment * If there is a change in work place within one year before the first day of the application period |
EXCEL |
| Survey Upon Approach of Qualification Acquisition * For those who have joined the association for less than 1 year and 6 months only the first application |
EXCEL |
| Situation Report Accompanying Claim for Injury and Illness Allowance, And Certificate of Consent * Only retirees |
EXCEL |
Post-retirement procedures
Want to continue joining the Health Insurance Society after retirement
* Depending on the reason for retirement, the national health insurance premium may be cheaper than voluntary continuation. Before applying for voluntary renewal, please contact the National Health Insurance window.
| Written Request to Acquire Qualification as a Voluntarily and Continuously Insured Person | EXCEL |
|---|
Name, address, etc. change
| Notification of Various Changes for a Voluntarily and Continuously Insured Person | WORD |
|---|
Lose the qualification of voluntary continuation
| Notice of Loss of Eligibility as a Voluntarily and Continuously Insured Person | EXCEL |
|---|
Lose your health insurance card, elderly beneficiary card, or certificate of limit application
| Insurance Card/Elderly Recipient/ Certificate Reissue due to Loss or Damage Application Form |
EXCEL |
|---|
Procedures regarding traffic accidents
If you are injured due to another person's activity such as a traffic accident (including bicycle) or a fight, you will need to submit the following documents and contact the Health Insurance Society to notify them.
In case of a traffic accident
| Notification of Injury or Illness Due to a Third-party Act (Traffic Accident) | EXCEL |
|---|---|
| Report on Circumstances related to the Occurrence of the Accident | WORD |
| Letter of Understanding(for the Insured Person) | WORD |
| Letter of Understanding(for the Other Party) | WORD |
| Statement of Reason for Inability to Obtain a Certificate of Accident Causing Injury or Death * Please be sure to submit if it is not treated as a personal injury accident. |
EXCEL |
In cases other than traffic accidents (such as fights)
| Notification of Injury or Illness Due to a Third-party Act (Other than Traffic Accident, such as Fights and Bite Wounds) | EXCEL |
|---|---|
| Report on Circumstances related to the Occurrence of an Accident (Other than Traffic Accident) | WORD |
| Letter of Understanding (for the Insured Person) | WORD |
| Letter of Understanding (for the Other Party) | WORD |